A report by the American Academy of Ophthalmology Ophthalmic Technology Assessment Committee Pediatric Ophthalmology/Strabismus Panel.Kara M. Cavuoto, MD,1 Melinda Y. Chang, MD,2 Gena Heidary, MD,3 PhD, David G. Morrison, MD,4 Rupal H. Trivedi, MD, MSCR,5 Gil Binenbaum, MD, MSCE,6 Stephen J. Kim,7 MD, Stacy L. Pineles, MD8
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Objective: To review the published literature assessing the safety and effectiveness of laser refractive surgery to treat anisometropic amblyogenic refractive error in children ≤ 18 years.
Methods: A literature search of the PubMed database was conducted in October 2021 with no date limitations and restricted to publications in English. The search yielded 137 articles, 69 of which were reviewed in full text. Twelve articles met the criteria for inclusion and were assigned a level of evidence rating.
Results: The 12 included articles were all level III evidence and consisted of 2 case-control studies and 10 case series. Six studies used laser assisted in-situ keratomileusis (LASIK), 2 used photorefractive keratectomy (PRK), 1 used refractive lenticule extraction/small incision lenticule extraction (ReLEX/SMILE), and the rest used a combination of LASIK, PRK, laser epithelial keratomileusis (LASEK), and/or ReLEX/SMILE. Five studies enrolled patients with anisometropic myopia, 3 with anisometropic hyperopia, and the remainder were mixed. Although all studies demonstrated an improvement in the best corrected visual acuity (BCVA), the magnitude of improvement varied widely. As study parameters varied, a successful outcome was defined as residual refractive error of 1 diopter (D) or less of the target refraction since this was the most commonly used metric. Successful outcomes ranged between 27% and 87%, with a mean follow-up ranging from 4 months to 7 years. Despite this wide range, all studies demonstrated an improvement in the magnitude of anisometropia. Regression in refractive error occurred more frequently and to a greater degree in myopic eyes and eyes with longer follow-up, and in younger patients. Although one study reported 2 free flaps, most studies reported no serious adverse events. The most common complications were corneal haze and striae.
Conclusions: Findings from included studies suggest that laser refractive surgery may address amblyogenic refractive error in children and that it appears to decrease anisometropia. However, the evidence for improvement in amblyopia is unclear and long-term safety data are lacking. Long-term data and well-designed clinical studies that use newer refractive technologies in standardized patient populations would help address the role of refractive surgery in children and its potential impact on amblyopia.
1Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, Florida.
2Children's Hospital of Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
3Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
4Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tennessee
5Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, Charleston, South Carolina
6Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
7Department of Ophthalmology, Vanderbilt University School of Medicine, Nashville, Tennessee
8Jules Stein Eye Institute, Los Angeles, California